Articles tagged with: psa

Jeremy Grummet is a Urological Surgeon with particular expertise in urological cancer. He has been instrumental in the introduction of transperineal prostate biopsy as an alternative to transrectal biopsy, to reduce infection rates after biopsy. Jeremy is conducting multiple clinical research projects on prostate biopsy and heads the Victorian Transperineal Biopsy Collaboration (VTBC) research group. In this article, Jeremy discusses the techniques and advantages of transperineal biopsy.

What’s wrong with the current standard method of prostate biopsy?

A biopsy is where a sample of tissue is taken for examination under a microscope, usually to determine if cancer is present. As you can see from the diagram below, the easiest way to access the prostate is via the rectum. That’s why we perform a rectal examination - so we can feel the back of the prostate for any suspicious lumps. Most prostate cancers are located towards the back of the prostate (peripheral zone), so a transrectal ultrasound-guided (TRUS) biopsy is a convenient way of sampling this area. Typically, at least 12 cores of tissue are taken during a TRUS biopsy.

The other advantage of the TRUS biopsy is that it can be performed in just a few minutes by giving the patient intravenous sedation or using a local anaesthetic nerve block.

However, passing the needle of the biopsy gun through the wall of the rectum multiple times is problematic. As you’d expect from an organ that stores faeces, the rectum has a high concentration of bacteria. These bacteria don’t cause any problems as long as they stay in the rectum. However, passing the biopsy needle through the wall of the rectum allows these bacteria to access the prostate and its rich blood supply. This in turn can lead to a serious infection in the blood called septicaemia (sepsis). Septicaemia makes patients feel very unwell, requires hospitalization for intravenous antibiotic therapy, and can even be life-threatening.

This risk of sepsis in TRUS biopsy is well-recognised. It is therefore standard to use an antibiotic to help prevent such an infection. Unfortunately, the antibiotic doesn’t always work, so there is still a risk of sepsis, which has been measured at about 1-2%.

Today, there is the additional and growing problem of bacteria developing antibiotic resistance. This has been reported worldwide and was the subject of a major US Government report last year.

Our own research group, the Victorian Transperineal Biopsy Collaboration (VTBC), reviewed the scientific literature, finding that developing resistance is a particular problem for bacteria that live in the rectum, so that the antibiotics we would normally use, such as ciprofloxacin, can sometimes be rendered ineffective. This coincides with reports of increasing rates of TRUS biopsy sepsis even as high as 5%.

Our research has also found that, as a result of the above, some Australian and New Zealand urology practices have resorted to using big-gun broad-spectrum antibiotics on a regular basis to prevent TRUS biopsy sepsis. Whilst this may reduce sepsis for the individual patient, from a public health perspective, it is a step backwards, as widespread use of such antibiotics will lead to even more resistance. Unfortunately, we are already seeing this happening, with hospitals in Australia finding CRE (Carbapenem-Resistant Enterococci) in their wards.

What is transperineal biopsy, and why is it safer?

Fortunately, there is another approach to prostate biopsy which avoids perforation of the rectum altogether. Instead, the biopsy needle can be passed via the skin of the perineum. In men, the perineum is the part of the body between the scrotum and the anus.

As shown in the diagram, the ultrasound probe is still passed into the rectum to provide an image of the prostate. But instead of the biopsy needle passing alongside the probe, it is passed through a grid, which itself is fixed against the probe outside the body. Prior to insertion of the ultrasound probe, the perineal skin is easily prepared in a sterile fashion, just as any other incision site is prepared before surgery to prevent wound infection. (Although worthwhile attempts have been made to sterilize the rectum, this has not been possible.)

Our group studied the experience of transperineal (TP) biopsy around the world and found that in over 6,600 patients, there were only 5 patients re-admitted to hospital for sepsis - a rate of just 0.076%, or less than 1 in a thousand. Furthermore, in our own published experience of 245 TP biopsies our rate of re-admission for infection was zero. (We have now performed over 400 TP biopsies, still without a single episode of infection.)

Based on the published scientific evidence to date then, it appears that TP biopsy is a safer option than TRUS biopsy due to its near-zero sepsis risk. It also gives the advantage of avoiding regular use of heavy-duty antibiotics, thereby avoiding promotion of resistant bacteria, now labelled by the US Government Center for Disease Control as a Serious Threat to population health worldwide. As a result, we now use TP biopsy routinely for all prostate biopsies.

Are there any downsides to the transperineal approach?

Looking at the diagram above, you would expect TP biopsy to be painful, which is why it is typically performed under a general anaesthetic (although methods of using local anaesthetic only have been reported). We routinely perform TP biopsy under GA. As a result, men experience no pain during the procedure, and very little afterwards, so that paracetamol is only required occasionally. Although a general anaesthetic is required, it is of a short duration only (less than 30 minutes) and is very safe.

Practitioners of TP biopsy initially reported a higher risk of acute urinary retention (unable to pass urine) with this approach. However, with further experience, and by deliberately avoiding the area around the urethra, this rate dropped so that it is now similar to the risk seen in TRUS biopsy (around 2%). Although a catheter has been used by some doctors, as shown in the diagram above, it is unnecessary.

Due to anecdotal experience, some urologists have been concerned that TP biopsy may lead to erectile dysfunction by damaging the erectile nerves or to more difficult surgery if cancer is found and the prostate needs to be removed. However, evidence to date, albeit scant, does not support either of these concerns.

Is it as good as TRUS at cancer detection?

According to the scientific literature, TP biopsy is at least equivalent to TRUS biopsy in its ability to detect cancer. Some research has also found improved detection of cancers at the front of the prostate (anterior). This may be due to the typically easy access TP biopsy provides to all areas of the prostate, particularly anteriorly. Conversely, it can often be difficult to reach the anterior prostate via TRUS biopsy, especially in large glands.

What other advantage might TP biopsy provide?

In TP biopsy, the ultrasound probe is stabilized by equipment that is fixed to the operating table. The grid through which the biopsy needle is passed is, in turn, stabilized against the ultrasound probe. This set-up permits accurate and reproducible biopsy needle placement.

In the past, TP biopsies were taken in a systematic fashion only, evenly sampling various areas of the prostate. Whilst this is still performed routinely, in addition we are now often performing targeted biopsies of suspicious lesions if found on a prostate MRI. The stable arrangement of TP biopsy therefore permits accurate targeting of such lesions, with the potential to further improve the accuracy of cancer detection.

The first guest blog for February is by Jim Duthie, a Urologist in Tauranga, New Zealand. Jim has written two Apps to make it easier for patients to be actively involved in their prostate cancer management. One app helps track PSA over time along with a history of prostate biopsies and treatments. The other greatly helps consolidate treatment for patients who are on ADT (hormone treatment).

For any question, the clichéd answer is now “There’s an App for that”, referring to the ubiquitous mobile applications for smartphones that seem to solve many of our problems, real or imagined. For medical conditions, this is increasingly the case. The “Medical” category is currently the most rapidly growing domain in the Apple App store. You can now download anything from a nomogram for predicting your risk of heart disease, to the somewhat questionable App that can treat whatever ails you by using your iPhone torch as a form of phototherapy. For me, designing mobile Apps was an effective solution for specific problems facing Urology patients.

Androgen Deprivation Therapy App

The process began with a concern that men undertaking Androgen Deprivation Therapy (ADT) were poorly followed up in terms of the myriad potential side effects that this treatment causes, from bone density to dyslipidaemia, to depression, and hot flushes. It is unclear exactly how many men are receiving ADT, let alone what percentage receive adequate follow up care. As Urologists, we are not experts in managing the complexities of, for example, cardiac risk factors.

Despite best intentions, we also lack the time and expertise to manage depression and cognitive impairment. It makes sense for General Practicioners/Family Physicians (GPs/FPs) to coordinate this follow up, but the physiological effects may seem complex and intimidating for a non-specialist. Perhaps Endocrinologists may be better equipped, but not from the point of view of coordinating patient management, and again a GP/FP usually has a better understanding of psychosocial issues. With this lack of clarity around responsibility it is easy for uncomplaining patients to slip through the cracks.
In practice, men receiving ADT may only attract medical attention after suffering a significant complication of their treatment.

To improve this situation, I considered that a centralized ADT database where men are recruited at the time of initiation of therapy, then sent reminders at regular follow up intervals would be ideal, and could additionally provide a bank of men available for clinical trials and retrospective study. Unfortunately, database creation and management is prohibitively expensive, and despite my best efforts such a structure is some way off yet.

I identified the core follow up issue as being getting the right investigations performed at the right time. To achieve this GPs/FPs need to be aware of the necessary tests, and patients informed about when to see their doctor for follow up. The ADT App attempts to achieve this with automated “push notifications” (alerts appearing on the smartphone) when they are due to see their GP, as well as listing recommended investigations according to the elapsed time since commencing treatment. The patient can also read about potential side effects by body system, and follow links for explanations about why the specific tests are required in terms of the physiological effects of androgen deprivation. This is an App aimed at patients, however the intention is that a GP/FP could also have this on their phone as a reference and educational aid.

PSA Manager App

This App addresses a broader group, any man either undertaking prostate cancer treatment or PSA screening. The idea of a “PSA Tracker” is not new. Before the advent of iTunes I encountered a retired accountant who had graphed his PSA over time by hand. An electronic equivalent is easy to achieve, but does it add much to the patient’s care? I thought that an “all in one” manager for prostate cancer screening and treatment would be more useful. The PSA Manager App allows the input of results of prostate biopsies, dates and modalities of treatment for cancer and benign prostate disease including surgery, radiation, and newer novel techniques, and results of imaging investigations such as CT, MRI, or bone scans with a facility for entering a free-text description of the results of these. The data are then presented on a graph with colour-coded markers to represent the timing of the interventions. PSA velocity and doubling time can also be calculated. The intention is to allow men a clear overview of their PSA changes during screening, and if applicable, the evolution and treatment of their prostate cancer.

Identifying barriers to care is an essential part of equitable health delivery, and something I considered at length. The first challenge I identified for men using these Apps, particularly the ADT App, was advanced age. We may think of men on ADT as being elderly, perhaps frail, and probably not expert in using technology. Firstly, this perception ignores the group of men receiving ADT as neoadjuvant/adjuvant treatment for radiation therapy, which constitutes a younger and healthier cohort of men. Secondly, many ADT patients attend clinic with a younger family member, and my experience has been that when I ask if anyone in the family has an iPod, iPad, or iPhone, the answer is usually yes. As long as one tech-savvy person can enter the data, the Apps work well by proxy.
In designing the interface, details such as larger buttons to suit male fingers and presbyopic vision were considered.

Finally, any financial cost will constitute a barrier to some patients. The solution was the make the Apps free to download. This meant securing funding which was generously provided by unrestricted grants from Australian Prostate Cancer Research and Ipsen for the ADT and PSA Manager Apps respectively. Although I receive no reimbursement from the development of either App, I believe patients feel more confident in a product provided solely for their benefit, and I can promote the Apps to them and my colleagues with no financial conflict of interest.

This week’s Guest Post is by highly regarded expert in the early detection of prostate cancer, Dr. Stacy Loeb. Stacy takes questions on prostate biopsy, and discusses its use, potential problems, and some developments in the field.

Dr Stacy Loeb is an Assistant Professor of Urology and Population Health at New York University (NYU) and the Manhattan Veterans Affairs Medical Center, specializing in prostate cancer. Dr. Loeb has published over 170 peer-reviewed articles and 8 book chapters, primarily on prostate cancer. She is on the Editorial Board for the British Journal of Urology International and Reviews in Urology, and authored the chapter on “Early Detection, Diagnosis, and Staging of Prostate Cancer” for Campbell-Walsh Urology, the primary textbook for the field. Stacy also frequently gives international lectures and courses on prostate cancer for other urologists, and hosts the Men’s Health Show on Sirius XM 81 satellite radio.

Stacy, TRUS biopsy is the most common technique for the diagnosis of prostate cancer. Can you give us an idea of the potential complications and the rates at which they occur?

The most common complication of prostate biopsy is bleeding, which can be in the urine, stool or ejaculate. Fortunately in most cases it is mild and self-limiting. Less common but often more serious is the potential for infection after biopsy. Indeed, the frequency of serious infections requiring hospitalization after prostate biopsy has increased in recent years. Other potential complications of prostate biopsy include pain and urinary difficulties, which are usually transient.

Is it a painful procedure to have done, and what techniques are used to reduce pain?

Prostate biopsy can cause both discomfort and anxiety, although there are many ways to mitigate these problems. Optimising patient positioning and simple relaxation techniques (such as deep breathing, listening to music, or even medication) may be useful to reduce anxiety. For pain, many different anesthetic options are available. For transrectal biopsy, several studies have shown that lidocaine jelly can ease insertion of the ultrasound probe, which is among the more uncomfortable parts of the procedure. Periprostatic nerve block is also commonly employed to successfully reduce pain during outpatient transrectal prostate biopsies. Other forms of biopsy such as the transperineal approach are frequently performed under sedation/general anesthesia, also effective forms of pain control. Overall, there are very few high-quality studies comparing the different methods for pain reduction during prostate biopsy, so the choice may be governed by patient-specific and procedural factors.

Some men require more than one biopsy to diagnose prostate cancer. There has been concern that repeat biopsies can predispose men to erectile dysfunction; can you comment on this?

There is conflicting evidence on the link between repeat prostate biopsies and the risk of erectile dysfunction. A study from the Johns Hopkins active surveillance program suggested that greater biopsy number was associated with erectile dysfunction after adjusting age, prostate volume and PSA, but a similar study from UCSF failed to confirm these results. Possible mechanisms for a link between repeated biopsies and erectile dysfunction include psychological factors as well as potential inflammation in the area around that prostate that houses the nerves involved in erections. Although this issue remains unresolved at this time, each procedure has potential risks making careful patient selection of critical importance. Hopefully, ongoing improvements in markers and imaging will reduce the need for repeat biopsies in the future.

You mentioned infection rates above. Are we seeing a rise in infection following TRUS biopsy of the prostate, and if so, why?

In the United States Medicare population, our research group reported a recent increase in hospitalisations for infection after prostate biopsy. Similar results have been confirmed in other populations, including Canada and Europe. The most likely explanation for these findings is increasing antimicrobial resistance in the community. Traditionally, the majority of patients were given fluoroquinolones as prophylaxis for prostate biopsy, but fluoroquinolone resistance has been on the rise. As a result, recent studies have explored other options for prostate biopsy prophylaxis, One option is to use more broad-spectrum antibiotics, although this may ultimately lead to greater antibiotic resistance in the future. An alternative option is to tailor the antimicrobial regimen based upon the local hospital antibiogram or individual rectal swab cultures performed at the visit prior to prostate biopsy. Other key recommendations are to assess the patient for risk factors for a prostate biopsy infection (such as diabetes, recent antibiotic use and foreign travel) and to counsel patients to seek immediate medical attention at the first sign of an infection.

Transperineal biopsy is another way to biopsy the prostate. Can you outline the advantages and disadvantages of this technique?

In the United States, most prostate biopsies are performed in the outpatient clinic through the rectum (transrectal) using ultrasound guidance. An alternate way to access the prostate for tissue sampling is through the skin of the perineum. Recent studies have suggested that the transperineal approach may reduce the risk of infectious complications. However, unlike transrectal biopsy, it is typically performed in the operating theatre with general anesthesia, thus involving greater time and expense. Transperineal prostate biopsies may also involve a greater risk of urinary retention, a situation where the patient is temporarily unable to urinate.

There has been a lot of interest in the use of MRI as a way of reducing 'unnecessary' biopsies. What are your views on this?

MRI technology has advanced substantially in recent years. At New York University, we have a well-established prostate imaging program using a 3 Tesla multiparametric MRI without an endorectal coil. Most patients tolerate the procedure well and it provides a very detailed anatomic view of the entire prostate, including regions that are poorly sampled during a traditional prostate biopsy. Suspicious lesions found on MRI can then be targeted during the prostate biopsy as a way to increase diagnostic yield. MRI may be particularly useful for men with a persistently elevated PSA and previous negative prostate biopsies, as well as for monitoring patients during active surveillance.

Matthew Cooperberg is Associate Professor of Urology and Epidemiology & Biostatistics at the UCSF Helen Diller Family Comprehensive Cancer Center. He is a urologic oncologist specialising in prostate cancer management. Matt is a highly published academic surgeon, having written/co-authored 130 peer-reviewed journal articles and 12 book chapters. He is Associate Editor for European Urology and sits on multiple other editorial boards.

Declan Murphy is Uro-Oncologist and Associate Professor of Surgery at the University of Melbourne, Peter MacCallum Cancer Centre. He is an Associate Editor at the BJUI and holds other senior editorial positions at European Urology and Nature Reviews Urology.

Declan, what was the rationale behind writing the Melbourne PSA Consensus Statement?

“The Melbourne Statement was a response to the very confused landscape we found ourselves in after the release of the USPSTF Recommendation last year and to a lesser extent, the AUA PSA Guideline a few months ago. While the USPSTF recommendation was frankly ridiculous and unworkable (PSA is not going to go away), the AUA Guideline did have some merit. However we felt that it did not adequately address some areas, e.g. how should we approach the average man in his 40’s who does not want to die of prostate cancer? Knowing that we would have a gathering of highly respected experts in prostate cancer in Melbourne in August 2013 we decided to release a simple document, which would provide straightforward guidance for GPs and others.”

Matt, has the statement been well received by Urologists, Patients and GPs/Family Doctors in the US?

“I was quite impressed with the press coverage in Australia and even in the U.S. when it was presented at the PCWC conference in Melbourne. We’ll see how much more discussion it generates when the final document is published in British Journal of Urology International. Ultimately, though, at least in the U.S., urologists’ recommendations don’t carry much weight with the primary care providers who are really making PSA testing decisions. They give far more credence to the USPSTF, unfortunately. Likewise in Australia, the RCGP Red Book is the bible for many GPs and it is very anti-PSA testing. Nevertheless we have had much positive feedback from GPs already.”

Matt, the USPSTF position statement essentially came out against PSA testing. Has this had a measurable impact on PSA testing in the US?

“This is hard to say so far. In 2009 the USPSTF came out against testing among older men, and multiple papers have shown that the recommendation had virtually no impact on PSA testing rates in the older population. However, this time it seems to be different. While there are no published data yet, multiple anecdotes seem to suggest that many primary care providers are simply abandoning PSA testing—equally for younger men in good health as for older ones with significant comorbidity. It is very much a case of throwing the baby out with the bath water.”

Matt, if the reductions in metastasis and prostate cancer mortality with PSA testing are so large, why does the consensus not support a population-wide screening programme?

“That term (population-wide screening) tends to imply reflexive PSA testing without any a priori discussion with the individual man. Enough controversy and confusion exists regarding both screening and prostate cancer treatment—and overtreatment is still enough of a problem in the U.S. and elsewhere—that we should not be screening men without warning them of the possible outcomes of testing. The relative cancer-specific mortality reductions are large, but the absolute reductions are not with 10-15 year follow-up, thus leading to calculations of relatively high numbers needed to screen and diagnose to prevent one cancer death. Though these numbers fall substantially with longer follow-up (a horizon of 30 years or more is entirely appropriate for a 50 year old man facing a screening decision), most men with prostate cancer die of cardiac disease, just like those without prostate cancer.”

Declan, are there any improvements or changes to the document planned?

“The document is set to evolve. One of the benefits of publishing it as a blog at bjui.org was to get it into circulation very quickly and also to allow others to comment. Within 72 hours the Melbourne Statement had become the most-read and most-commented blog at BJUI. The print version will appear in the BJUI in coming months.”

Matt, what is the future for PSA testing in your view?

“It’s very hard to say. I think many of us know the way PSA screening should evolve: men should be offered testing at a relatively young age—with the express understanding that testing is intended to detect high-risk prostate cancer, and that if a low-risk tumour is identified, it does not need immediate treatment. Those with low baseline PSAs can be re-screened less frequently than they are now. Evolving biomarkers will help determine who needs a biopsy and who needs treatment, but PSA is not going anywhere as a first screen. From what I understand, most national policies are evolving toward some variation on a “smarter screening” approach. Unfortunately, in the U.S. it will likely require a legislative remedy to force the USPSTF to accept actual expert opinion before the policy is corrected. There is a bill working its way through Congress to do just this, but it is not a quick process.

"In the meantime, the best we as urologists can do is to implement smarter screening in practice, to strive to reduce overtreatment and to improve quality of treatment when it is needed, to continue to advocate for USPSTF reform, and to reach out to local groups of primary care providers to educate them that the truth about PSA—which, as is usually the case in medicine, is neither black nor white. Only through understanding the truth in the shades of grey can we at once maximise the benefits of screening and minimize its harms.”

Continuing the Guest Post series, this week David Merry talks about his role as Secretary of the South Australia and Northern Territory Chapter Council of the Prostate Cancer Foundation of Australia. David is also Chairman of the Prostate Cancer Action Group (SA) Inc. Locally, these groups provide great levels of support to men with prostate cancer and their families

"The Central Australia Chapter Council is the 'organ' for SA & NT set up by PCFA to back up and provide support for the PC Support Groups in both States (there are 17 Groups), and currently I am Secretary. There are 9 members sourced from the Support Groups from both SA & NT. We meet every two months and for the past year David Sandoe the Chairman of the National Board has come across from Sydney to attend meetings and report on the National Office activities. Earlier in 2013 PCFA established the office at 144 South Terrace, from which Ian Richards, the appointed Outreach and Support Group Officer operates, along with Karyn Foster, State Manager for PCFA , a vibrant PR professional whose principal activity is organising fund raising. Karyn is also the Secretary for the PCFA State Board comprising about 10 prominent professional and business people who support her with fund raising. Professor Villis Marshall is the Chairman.

"My other role is Chairman of the Prostate Cancer Action Group (SA) Inc, a small group of 'survivors' which concentrates on presenting Awareness Evenings around the State. Over 14 years we have held about 35 such evenings, and we also present Information Stalls at Field Days, Country Shows, Men's Health Expo's etc. We have always enjoyed great support from many Urologists, and we operate as an adjunct group under the Chapter Council, with financial support from PCFA and from our own fund-raising. Often following an Awareness Night, we have been able to then set up a Support Group in the town or area.

"I am aware that most men diagnosed with prostate cancer in Adelaide have no contact with a Support Group and that many would benefit from information and the opportunity to speak with others who have journeyed through prostate cancer which is available through the groups. Partly this is of our making as currently we do not have a concise & encouraging brochure listing SG meeting details suitable for Clinic notice boards. PCFA have a wealth of up to date material, and in May this year held a Training Conference for 'delegates' from every SG in the nation (about 140), all expenses paid, in Melbourne, to promote current information, to help ensure that what information was discussed at SG's would be accurate and up to date.

"Our experience talking with men who have been treated invariably reveals comments suggesting they are traumatised at the time of being diagnosed, feel they are not well informed, fear for the outcomes, effects of treatment etc. Currently we are also hearing that some say their GP's are reluctant to offer them a PSA test, not keen to perform a DRE, and will only order a blood test under duress.

"I have heard from several sources lately that the Information Sessions offered at Calvary Hospital are most helpful and well received by men recently diagnosed (and their wives). This is good news.

"This is just what should be available for every man in this position and an aspect that needs to be expanded. The Royal Adelaide Hospital is fortunate to have a PCFA-funded Prostate Cancer Nurse on hand, and hopefully SA will score at least one more Specialist PC Nurse from the next intake being planned by PCFA. The Action Group funded two nurses (one from the Riverland and one from Adelaide Hills Community Health Service, Mt Barker) who are studying the external Latrobe University Course semester right now. At the time we advertised the scholarships, there were applicants from Calvary and other Adelaide hospitals, but none from Urologists Clinics in Adelaide."

David Merry trained as a Pharmacist, and while working at the Adelaide Children's Hospital, completed a Science Degree in Biochemistry and Microbiology, after which he worked at the Institute of Medical & Veterinary Science in Adelaide as a Microbiologist and later as Serologist for 30 years.
Eight years ago he was diagnosed with Prostate Cancer from PSA studies, underwent nerve sparing radical surgery, followed 18 months later with radiotherapy, and has since been declared by his Urologist as 'cured'. After such a positive out-come and retirement he volunteered as an Ambassador Speaker for the PCFA, then became involved with the Prostate Cancer Action Group and the Prostate Cancer Central Australia Chapter Council as Secretary.

This is the first in a series of posts by highly respected guest authors.

This week, Henry Woo, a Urologist from NSW, gives a balanced and concise view of the current controversies surrounding PSA testing.

“As an urologist who has subspecialized in just the area of prostate disease, I see men with prostate cancer every working day. Every single consulting session I will see a number of men with advanced prostate cancer who are enduring either the side effects of the palliative drug treatment for advanced prostate cancer or who are battling the complications associated with advanced prostate cancer.

In Australia, over 3,200 men die from prostate cancer each year. This is a greater number than the women who succumb to breast cancer each year. Irrespective of what the denominator is in terms of how many are diagnosed each year, as the second greatest cause of cancer specific deaths in men (after lung cancer), it is continues to astound me that anybody can sweep these facts under the carpet. But to give the denominator, number of men who are diagnosed with prostate cancer in Australia each year currently sits at just under 20,000.

It is well recognized that not all men diagnosed with prostate cancer will actually die from their cancer but will instead die from some other cause. The majority of cancers will follow an indolent slow growing course and will never cause harm. This said, these statistics include men who in spite of dying with prostate cancer (and not from it) have significantly suffered from the effects or treatment for advanced prostate cancer or were successfully treated for prostate cancer that otherwise have lead to a prostate cancer related death.

The overzealous desire to fight prostate cancer has had significant consequences. Many men who did not need treatment have been unnecessarily treated and of these, some have experienced complications associated with radical treatment. This has been a huge problem and with its recognition, attempts are being made to rectify this problem. Significant progress has been made in getting smarter about who needs treatment and also reducing the risks of complications associated with treatment.

Not all men diagnosed with prostate cancer need treatment. There has been a major shift towards treating early stage prostate cancer conservatively by what we call active surveillance and watchful waiting. Active surveillance differs from watchful waiting in that curative treatment has not been ruled out. Active surveillance is a program of monitoring that attempts to strike the right balance between avoiding the overtreatment of prostate cancer yet at the same time attempting to minimize of missing any window of opportunity to deal with the cancer should it subsequently prove itself to be more aggressive than originally anticipated. Protocols for active surveillance vary but contemporary monitoring includes monitoring PSA blood test levels and periodically carrying out MRI scans of the prostate or progress biopsies. If there is evidence that suggests that the cancer is more aggressive than originally thought or if the disease appears to have progressed, the option of treatment remains on the cards. Watchful waiting implies that curative treatment has been ruled out and monitoring is carried out until such time that the disease progresses to justify the commencement of palliative drug treatment in the form of androgen deprivation therapy (commonly referred to as hormone therapy).

There has also been a significant improvement in side effects associated with treatment for prostate cancer. The majority of men with very early stage prostate cancer are candidates for treatment that can spare both urinary and sexual function. Commonly, detractors against prostate cancer testing attempt to connect urinary incontinence and erectile dysfunction as being consequential certainties associated with prostate cancer testing.

Now on the issue of PSA blood testing, there have been quite polarized views on whether it should be performed or not. I have tried to avoid the word ‘screening’ because I think that most of us who have in the past supported this approach have moved very much towards selected testing on an individual basis where each man as an individual has the opportunity to participate in the decision to undergo testing or not.

I think that it is time that those who so vehemently oppose PSA testing acknowledge that an entity that is the second greatest cause of cancer related death in men is a major public health problem. It is also time to stop assertions that if a PSA test is abnormal that it leads to a high risk of complications with the biopsy and that should cancer be confirmed that it some form of aggressive intervention will invariably follow. Additionally, we have moved on from the outcomes of 20 years ago in that treatment is NOT invariably associated with incontinence and erectile dysfunction.

The answer for PSA testing lies somewhere between widespread population screening and totally opposing any form of testing at all. I am looking forward to those who have vehemently opposed any form of testing for prostate cancer to acknowledge this as well.

Concluding Comments

I am NOT in favor of indiscriminate population screening for prostate cancer. Men should be risk assessed as to whether the benefits of making a diagnosis of prostate cancer individually outweighs the attendant risks. Men should NOT be denied the right to participate in any discussion regarding a decision to undergo prostate cancer testing or not. I completely disagree with any assertion that there should no discussion about prostate cancer testing unless raised by the patient. When men are counseled on making a decision as to whether or not they wish to be tested, they should be given information that is relevant to their individual circumstances. The Melbourne Consensus Statement on Prostate Cancer Testing is a good place to start."